Project Summary Cancer patients in rural areas have more limited access to specialized care, are less likely to receive certain treatments, and have poorer outcomes than their counterparts in non-rural areas. Over recent years, many rural hospitals have closed and a high proportion of remaining rural hospitals are in financial distress and at risk for closure, exacerbating barriers to care for rural patients. At the same time, evidence that the volume of surgeries performed in a hospital is associated with improved health outcomes, including mortality, has led to efforts to regionalize surgical care. Although the advantages of regionalization are well documented, referring cancer surgeries to high-volume centers presents challenges for patients, surgeons, and hospitals in rural communities. Against this complex backdrop, the state of Pennsylvania has initiated the Pennsylvania Rural Health Model (PRHM), an innovative program designed to provide hospitals with predictable revenue streams through global budgets and encourage participating hospitals to redesign care delivery to best meet the needs of their communities. This project will assess the impact of the PRHM on access to and outcomes associated with cancer surgery. First, we will examine the impact of the PRHM on regional cancer surgery delivery patterns by examining the location and characteristics of hospitals at which cancer patients receive surgery using statewide hospital discharge data. By decoupling payment from volume, PRHM changes the incentives for providers to perform surgeries locally versus referring patients to regional centers. We hypothesize that patients in areas served by PRHM hospitals will be more likely to be referred to high-volume centers than those in other rural hospital markets. Second, we will assess the effect of the PRHM on cancer surgery access and outcomes using linked discharge and cancer registry data. The PRHM emphasizes changes in care delivery that target improvements in population health, with a focus on access to specialty care. We hypothesize that surgical cancer patients in areas served by PRHM hospitals may experience improvements in receipt of recommended cancer surgery, time to surgery, and related health outcomes, including mortality and readmissions. Third, we will use qualitative methods to understand the PA Rural Health Model implementation process, including its impacts on resource utilization, hospital capabilities, staffing, care delivery, and financial incentives for providers. We will conduct interviews with key informants and focus groups with community stakeholders. Guided by a comprehensive conceptual model derived from implementation science, we will granularly assess the mechanisms by which PRHM succeeded or failed to affect hospital processes and outcomes for surgical cancer care. As the population in areas served by targeted hospitals continues to age, cancer incidence and the demand for high-quality surgical care will increase. Lessons from this context will be highly relevant for informing alternative payment models in rural hospitals and addressing the needs of surgical cancer patients in rural communities throughout the United States.